Realizou-se nos dias 6 e 7 de dezembro o 15º Curso Teórico Prático de Ultrassonografia para Gastrenterologistas no Hospital Amato Lusitano, em Castelo Branco sob a coordenação da Dra. Ana Caldeira e Dr. Eduardo Pereira. Veja algumas fotografias do curso.
Case Report A 26-year-old male with history of sleeve gastrectomy (4 years ago) was referred to the Gastroenterology outpatient clinic due to abdominal discomfort. On physical examination a hard, nontender, large abdominal mass was found. Abdominal CT scan revealed a 210×117 mm contrast-enhanced solid mass centered in the mesentery (Fig. 1a and 1b). There were no signs of bowel obstruction or evidence of lymphadenopathy. Figure 1. Abdominal CT (a – coronal view; b – axial view): contrast-enhanced solid mass centered in the mesentery. After multidisciplinary discussion, endoscopic ultrasound (EUS) with tissue acquisition was performed. The cranial portion of the abdominal mass was observed through the distal second portion of the duodenum. EUS demonstrated a hypoechoic heterogeneous mass with ill-defined borders (Fig. 2a). Real-time EUS elastography revealed a heterogeneous, predominantly blue (hard) pattern (Fig. 2b). Through the duodenum we performed EUS-guided fine needle core biopsy (EUS-FNB) using a 25G needle (Acquire™, Boston Scientific®). Figure 2. EUS (transduodenal view): hypoechoic heterogeneous mass with ill-defined borders; a – EUS – elastography: predominantly blue (hard) pattern; b – EUS-FNB. Quiz Discussion The histology specimen showed the presence of fusiform cells, without atypia (Fig. 3a and 3b). Imunohistochemical staining was positive for β-catenin (Fig. 3c) and negative for c-KIT, DOG-1, AE1/AE3, CD34, S100 protein, alfa-actin and MDM2. Figure 3. Patholohy: a and b – Presence of fusiform cells, without atypia (4x and 20x, respectively); c – imunohistochemical staining was positive for β-catenin (20x). The patient underwent surgical resection of the tumor that included segmental enterectomy […]
Case Report A 68-year-old man presented with weight loss (3kg in 5 months). His past medical history was remarkable for ART-controlled HIV infection (HIV viral load <20 and CD4+ lymphocyte count 692/uL). Review of systems revealed no other symptomatology. Chest X-ray showed a right-sided pleural effusion (Fig. 1). Figure 1. Chest x-ray (posterior-anterior view):right-sided pleural effusion. A diagnostic thoracentesis was then performed and revealed a very viscous yellow pleural fluid, which biochemical analysis was compatible with exudative effusion. Fluid cultures were negative. Cytological analysis of the pleural fluid showed morular papillary neoplastic cells with cytoplasmic vacuoles compatible with adenocarcinoma. However, cell block immunohistochemistry was positive for CK5/6 and negative for BerEP4, TTF1 and CDX2 favoring the diagnosis of mesothelioma. To assist the differential diagnosis a pleural biopsy was done but it was inconclusive due to insufficient material. A contrast-enhanced thoracic computed tomography (CT) was then performed and revealed a large right-sided pleural effusion and a 16x10x5cm hypodense non-enhancing posterior mediastinal mass, anterior to the vertebrae and causing esophageal and aortic artery axis deviation, without invasion or pleural thickening; no parenchymal lung masses or lymphadenopathies were seen (Fig. 2). Figure 2. Thoracic CT (a – coronal view; b – axial view): large right-sided pleural effusion and 16x10x5cm hypodense posterior mediastinal mass. To further characterize this mediastinal mass an endoscopic ultrasound (EUS) was done and showed a very large well-defined rounded hypoechogenic mediastinal mass, located between 29 and 39cm from the incisors, adjacent to the esophagus and aorta, without invasion (Fig. […]
Case Report A 59-year-old woman with no relevant past medical history was referred to the Outpatient Clinic due to iron-deficiency anemia (minimum hemoglobin level of 6.8g/dL). Upper endoscopy showed a large smooth-surfaced polypoid lesion occupying most of the duodenal bulb (Figure 1). Ileocolonoscopy was normal. Figure 1. Upper endoscopy showed a large polypoid lesion covered with intact mucosa in the duodenal bulb. Endoscopic ultrasound (EUS) revealed a 36x24mm heterogeneous mixed echoic submucosal lesion with multiple cystic areas (Figure 2a), with a 14mm thick short pedicle (Figure 2b) and a feeding artery on color Doppler. Figure 2. EUS showed a larged mixed echoic submucosal lesion with cystic areas (Figure 2a), with a short pedicle (Figure 2b). Quiz Discussion Bite-on-bite biopsies were taken where Brunner’s glands hyperplasia was identified. Resection of the lesion with a hot snare after submucosal injection of diluted adrenaline was performed, without complications (Figure 3). Histopathologic diagnosis was Brunner’s gland hamartoma (Figure 4).Figure 3. Endoscopically ressected specimen. Figure 4. Photomicrograph of Brunner’s gland hamartoma. On 6-months follow-up, the patient has no anemia. Brunner’s gland hamartomas are rare and benign tumors that occur mainly in the bulb, with less than 200 cases reported in the literature1. Most cases have been reported between the ages of 50 and 60 years, with no gender predominance2. They consist of abnormal proliferation of Brunner’s glands embedded in a fibrous stroma with bundles of smooth muscle and cystic dilated ducts1. Hyperplasia is the designation for lesions smaller than 5mm, which can be diffuse […]
Case Report An 81 year-old anticoagulated male patient, with a medical history of atrial fibrillation and valvular cardiomyopathy, performed a total colonoscopy due to intermittent hematochezia, which revealed in the distal rectum a well-defined and regular protruded sessile lesion with 16 mm (T0 Is) (Figure 1). Figure 1. Protruded sessile lesion (T0 Is) with 16 mm, in the distal rectum. Endoscopic ultrasound examination (EUS) identified a hypoechoic lesion with clear margins arising from the second layer, without lymph node or muscular layer involvement (Figure 2). Figure 2. Hypoechoic lesion arising from the second layer. Quiz Discussion Abdomino-pelvic computerized tomography (CT) and PET-TC DOTA NOC showed no distant metastasis. Multidisciplinary evaluation was carried out and excision of the tumor by endoscopic submucosal dissection (ESD) was planned. The procedure was performed with no complications reported (Figure 3). Figure 3. A to F – Endoscopic excision of a rectal neuroendocrine tumor by endoscopic submucosal dissection (circumferential mucosal cutting and submucosal dissection performed with the Dual-Knife, Olympus®). Pathological analysis confirmed the diagnosis of a totally resected well differentiated neuroendocrine tumor (G1) with a low mitotic index (Ki67 < 2%) and no lymphovascular invasion. No distant metastasis were identified during the follow up period (2 years). The incidence of rectal neuroendocrine tumors has been rising largely due to an increased number of screening colonoscopies, allowing for identification of smaller lesions amenable to endoscopic treatment1. Indeed, endoscopic therapy of neuroendocrine tumours may be considered in lesions below 2 cm, without muscularis invasion according to the European Neuroendocrine […]
Case Report A 70-years-old man presented with weight loss. He reported heavy smoking and consumption of 2 units of alcohol per day. A thoracic and abdominal computed tomography was performed and revealed cephalic pancreatic enlargement with multiple calcifications scattered throughout the pancreas, a hypodense mass in the uncinated process and irregularly dilated main pancreatic duct. Endoscopic ultrasound showed multiple diffuse infracentimetric pancreatic cysts, most of which with small foci of mural calcification, communicating with the main pancreatic duct, two larger cysts with 20mm and 19mm in the head and uncinated process, respectively, with calcifiedmural nodules, and main pancreatic duct dilatation in the cephalic pancreas (max 4.6mm) (Figure 1) Figure 1 – EUS showed multiple diffuse infracentimetric pancreatic cysts communicating with the main pancreatic duct, with small foci of mural calcification. Quiz Discussion Endoscopic ultrasound-guided fine-needle-aspiration using a 22Gneedle of the largest cyst was performed with drainage of viscous fluid positive for mucin stain. Cytology was negative for malignancy and cyst fluid analysis revealed elevated amylase and CEA, consistent with multifocal branch-duct intraductal papillary mucinous neoplasms (IPMN) with psammomatouscalcifications. Although relatively rare, cystic lesions of the pancreas are considered to be an increasingly important category with a spectrum of histology and malignant potential1. IPMN are detected with increasing frequency as more patients are exposed to radiologic imaging modalities2. Calcifications within IPMN have been reported, with a frequency ranging from 10% to 25%, however its significance is still unknown2. They are usually focal and peripheral3.Punctate calcification have been seen in approximately […]
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US Quiz March 2018
Ultrasound Imaging Prize Deadline: April 30 2018